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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />J R. SMITH, CLERK <br />UNIMERICA INSURANCE COMPANY <br />A Stock Company <br />Administrative Offices: 11000 Optum Circle, Eden Prairie, MN 55344 <br />Phone: 1-800-454-0233 <br />APPLICATION FOR EXCESS LOSS INSURANCE <br />The undersigned Applicant requests the Excess Loss Insurance Benefits shown herein and provided by Unimerica Insurance <br />Company, and agrees to be bound by the terms and provisions of the Excess Loss Insurance Policy. <br />Full Legal Name of Applicant: Indian River County Board of County Commissioners <br />Address: 1800 27" Street, Vero Beach, FL 32960 <br />Key Contact: Suzanne M. BOVII Telephone: 772-226-1402 Tax ID: <br />59-6000674 <br />Applicant is a: ❑ Corporation ❑ Labor Union ❑ Partnership ❑ Association ❑ Proprietorship ® Other: County Government <br />Nature of Business of the Group to be Insured: County Government Requested Effective Date: October 1, 2022 <br />Total number of eligible persons: Employees: Retirees: Zg�, <br />Are retirees covered: ® Yes ❑ No. <br />Affiliates or Subsidiaries: <br />Addresses of Affiliates or Subsidiaries: <br />Full Name of Administrator: Blue Cross and Blue Shield of Florida Pharmacy Benefit Manager: RxBenefits, Inc. / ESI <br />Address: 4800 Deerwood Campus Parkway, Jacksonville, FL 32246 <br />Key Contact: Jacklyn LoDuca Telephone: 727-643-2950 <br />Agent or Broker: Lockton Companies <br />Tax ID: <br />Address: iloduca@lockton.com <br />SPECIFIC EXCESS LOSS INSURANCE ® Yes ❑ No <br />Benefit Period: Covered Expenses Incurred from October 1, 2021 through September 30, 2023 and <br />Paid from October 1, 2022 through September 30, 2023. <br />Specific Deductible: per Covered Person: $300,000 <br />Specific Percentage Reimbursable: 100% <br />Maximum Specific Benefit per Covered Person: ® Unlimited ❑ Other <br />Covered Expenses under Specific Excess Loss: ® Medical ® Stand Alone Prescription Drug Program <br />Common Accident Provision: ® Yes ❑ No <br />I Description: I Specific Premium Rates per month <br />62.51 <br />Specific Accommodation Reimbursement Endorsement [:]Yes ® No <br />Specific Step -Down Deductible Endorsement ❑ Yes ® No <br />Specific Terminal Liability Endorsement ❑ Yes ® No <br />Aggregating Specific Deductible Endorsement ® Yes ❑ No $100,000 <br />Independent Review Organization Extended Liability Endorsement ® Yes ❑ No <br />UMERAPP (01/12) <br />